Aria of Brookfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure resident's that were transferred to the hospital received the required notice information. This was observed with 5 (R65, R13, R10, R4 and R58) of 6 residents reviewed that were transferred out of the facility. * R65, R13, R10, R4 and R58, did not receive written notice at the time of transfer that included: A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility did not provide pharmaceutical services that assure proper dispensing of medications, did not ensure drug records are in order, and/or all controlled drugs are maintained and periodically reconciled. *The Facility did not ensure controlled substance logs were maintained for periodic reconciliation on units 1 [NAME] and 2 South. *The Facility did not ensure medication refrigerators were monitored for temperature control and did not ensure corrective action was implemented for frost accumulation build up for the medication refrigerators on 1 E/W (east/west) and 2 South. * R120 was observed to have a lidocaine patch dated 8/22/25 on 8/25/25 when the nurse went to place a new lidocaine patch. R120 was to have a new patch placed in the mornings and removed at bedtime on 8/23/25 & 8/24/25 to help control pain from rib fractures these were not administered to R120. Findings include: The Facility's policy titled, “CONTROLLED SUBSTANCE STORAGE”, with no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles, to include the expiration date when applicable for 2 of 2 medication carts observed.- 2 bottles of controlled narcotic medications were found in the top drawer of the medication cart, outside of the narcotic lock box. -numerous stock medications were observed on the carts past the manufacturers expiration date. -8 residents (R13, R53, R65, R29, R85, R88 and R84) of 8 resident using insulin pens did not have an open date and/or were past the discard date.-an unlabeled 1 milliliters (ml) syringe, with unknown clear liquid, was observed in the top drawer of medication cart. - 9 loose, unknown pills were found throughout the medication cart, the first 2 were thrown into the regular garbage.Findings include:The Facility's policy, titled CONTROLLED SUBSTANCE STORAGE, with no date, documents, . B. Schedule [II-V] medications and other medications subject to abuse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all residents that eat food prepared by the facility. *In the facility's main kitchen, observations of partially used and undated food were observed in the walk-in cooler, and a container with egg salad wrote on the label with an expired-on date that was already passed was observed. Open food was observed in the refrigerator in the resident 2nd floor main kitchen with no open or use by date. *Resident refrigerators on both floors had unlabeled and undated food items inside of them. Both resident refrigerators also had spilled liquids inside of them. *The resident refrigerator on the second floor in the 2 South medication room was observed to have multiple food items in the freezer that were unlabeled and there was an unknown brown matter, that appeared to have been a liquid spill that froze. *The first-floor resident refrigerator in the 1 East/West medication had brown liquid spills and numerous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (R18, R43. R50, R75 R120) of 5 residents. * The facility failed to ensure Clostridium Difficile (c-diff) Enteric Contact Precautions Policies were followed by staff when providing cares for R50. * The facility failed to ensure Enhanced Barrier Precaution (EPB) Policies were followed by staff when providing cares for R75. * The facility failed to ensure Enhanced Barrier Precaution Policies were followed by staff when providing cares for R18. * Staff were observed not sanitizing medical equipment and completing hand hygiene when providing care to R43. Additionally, staff were not observed to wear EPB when having high contact with R43. * Observations were made of an eye wash station and sink to be dirty and have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 1 (R119) of 1 sampled resident with an indwelling catheter received appropriate treatment enhancing self-esteem and providing dignity for R119. *R119 was observed multiple times with R119's catheter drainage bag uncovered in public view. Findings include: R119 was admitted to the facility on [DATE] with diagnoses including acute cystitis with hematuria (inflammation of the bladder with bleeding) and chronic kidney disease (long term damage of the kidneys)R119's Medicare admission Minimum Data Set (MDS) with an assessment reference date of 08/29/2025 documents under Section C cognitive patterns: a Brief Interview for Mental Status score of 15 indicating R119 has intact cognition. On 08/24/2025, at 9:52 AM, Surveyor observed R119's catheter bag not covered hanging on R119's bed facing the open door.On 08/25/2025, at 7:07 AM, Surveyor observed 119's foley bag with no cover on foley bag facing the open door. On 08/25/2025, at 11:07 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R26) of 1 resident's preference to receive double portions at mealtimes was implemented and that the resident (R26) was informed of changes in orders when request was revised. Findings include:The facility policy titled Resident Right-Right to Participate in Planning Care dated 1/11/2021 documents: Policy Statement: it is the facilities (sic) policy to provide care and services in such a manner to acknowledge and respect resident rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and received care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. Procedure: 1. The resident's right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: . c. The right to be informed, in advance, of changes to plan of care.R26 was admitted to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure psychotropic medications were limited to 14 days when ordered as needed (PRN) for 1 (R58) of 6 residents reviewed for unnecessary medications.R58 had an order on admission for the antianxiety medication lorazepam 0.5 mg every four hours as needed with no stop date at 14 days.Findings include:The facility policy and procedure titled Psychotropic Drug Use dated 4/1/2025 documents: F. PRN orders for psychotropic drugs are limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, her/she [sic] should document their rationale in the resident's medical record and indicate the duration of the PRN order.R58 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a brain dysfunction caused by metabolic disruptions possibly from liver or kidney disease) and anxiety.On 7/8/2025, R58 was admitted with an order for lorazepam…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure residents with an enteral tube (gastrostomy [PEG-tube]) receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This was observed with 2 (R43 and R20) of 3 residents observed with enteral tubes for feeding. * R43 did not have prescribed orders for enteral tube care and had unknown liquids in tube feeding administration bags hanging in their room. *R20 had tube feeding administered without any identifying labeling on the formula administration bag. The facility's policy and procedure “Placement and Residual Volume check for Enteral Feeding Tubes” dated 12/18/24, documents: 5. Monitor entry site for any signs of infection daily and notify physician as needed. 1.) On 8/24/2025, at 10:28 AM, Surveyor observed R43 in their room. R43 had a tube feeding pump, attached to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents receiving respiratory care was consistent with professional standards of practice for 1 (R8) of 1 residents reviewed for oxygen use.R8 was receiving oxygen via nasal cannula with no orders for oxygen therapy.Findings include:The facility policy and procedure titled Policy Oxygen Administration undated documents: Oxygen will be safely administered per physician's orders.R8 was admitted to the facility on [DATE] with diagnoses of displaced bicondylar fracture of the left tibia, pulmonary hypertension due to lunch diseases and hypoxia, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia. R8's admission Minimum Data Set (MDS) assessment dated [DATE] documented R8 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 and received oxygen.On 8/24/2025 at 12:44 PM, Surveyor observed R8 lying in bed. R8 had an oxygen concentrator delivering 4-1/2 liters of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure it maintained a medication error rate below 5 percent during observations of medication administration affecting 3 (R43, R49 and R120) of 3 residents observed. Seven medication errors were observed out of twenty-seven opportunities, for a total error rate of 25.93%. R43 was observed to receive 5 medications orally but her physician's orders documented to give the medication via her gastrostomy (G) tube. R49 was observed to receive 5,000 International Units (IU) of Vitamin D but her physician's orders documented to give 50,000 IU of Vitamin D. R120 was observed to receive expired calcium carbonate.Findings include:On [DATE], the facility's policy titled Medication Administration - General Guidelines dated 12/19 was reviewed and documented: 5 rights: Right resident, right drug, right dose, right route and right time. Medications are administered in accordance with written orders of the prescriber. 1.) R43 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure there were systems in place to establish coordination of care services between the facility and contracted hospice services for 1 (R113) of 4 residents reviewed for receiving hospice services. *The facility did not ensure Hospice required documentation was maintained in R113's medical record. The facility did not have an order for hospice services in R113's orders. The facility did not have a care plan for hospice services started after admission on to hospice services. Findings include:R113 was admitted to the facility on [DATE] and has diagnoses that include malignant neoplasm of unspecified part of right bronchi or lung, encounter for palliative care, unspecified protein - calorie malnutrition. R113's admission minimum data set (MDS) was still in progress, R113 was admitted into Hospice on 8/15/2025 with diagnoses of malignant neoplasm of lung. Surveyor observed a Discharge summary, dated [DATE] admission Narrative: Patient advised to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility document and policy review, the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within two hours for 1 (Resident #3) of 3 sampled residents reviewed for abuse. Findings included: An undated facility policy titled, Abuse Prevention Program, specified, VII. External Reporting 1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or the designee, shall complete and submit a DQA [Division of Quality Assurance] form F-62617, notifying DQA that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated. This report shall be made immediately. The term immediately as it is used in this policy in relation to reporting abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and suspicion of a crime shall defined as,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, and interviews, the facility failed to ensure the facility wide security alarm system is communicated throughout the facility when triggered. This failure indicates a critical gap in the alarm system's ability to effectively alert staff facility-wide during a potential security or emergency event. This finding suggests a limitation in the current alarm system's ability to communicate alerts comprehensively across all critical areas within the building which could potentially affect the safety of all residents and staff. Findings include: Observations on 05/08/25 at 5:05 AM two surveyors entered the facility through the front entrance, which was found to be unlocked. Upon entry, a loud screeching noise consistent with an activated alarm was heard. The surveyors proceeded through the main facility lobby, estimated to be approximately 50 yards in length, and entered through a single interior door leading to the first nursing station, identified as One South. Upon arrival at the nursing station, a wall-mounted security panel located on the back wall displayed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, document review, and policy review, the facility failed to ensure that at the completion of the narcotic count both nurses who participated in the counting documented the accurate count at the change of each shift for three of four medication carts (1 South, 1 East, and 2 South B) reviewed for accuracy of narcotic counts. As a result of this deficient practice, not signing the correct narcotic count creates the potential for misappropriation of narcotics and missed doses for residents. Findings include: Review of the facility policy titled Medication Storage in the Facility: Controlled Substance Storage, revised January 2018, revealed, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and policy review, the facility failed to protect the resident's right to be free from abuse by a family member for one of three residents (Resident (R)17) reviewed for abuse out of a total sample of 23. R17 experienced an altercation with his family member (FM2) during a family visit and FM2 hit R17 on the forehead. Failure to protect resident from abuse had the potential to result in injury to residents. Findings include: Review of the facility's undated policy titled AA Healthcare Abuse Prevention Program Revealed, This facility affirms the right of our residents to be free from abuse, neglect, . or mistreatment. This facility therefore prohibits abuse . and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse . of residents. Review of R17's admission Record located in the electronic medical record (EMR) under the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to ensure medications were secure and medication carts were locked for two of two medication carts observed at the second floor south nursing unit. As a result of this deficient practice medications may be unsecured and available for diversion. Findings include: Observation on 05/08/25 at 5:15 AM, at the nursing station on 2 South, no staff were in sight. A resident was ambulating near the station, and there were 15 medication cards sitting on the desk, out in the open, unsecured. Observation on 05/08/25 at 5:15 AM, at the nursing station on 2 South, no staff were in sight. Two medication carts were parked near the station and both medication carts were unlocked and drawers containing the medications for the residents were able to be opened. During an interview on 05/08/25 at 5:20 AM, Licensed Practical Nurse (LPN)6 confirmed the medications left on the desk were not secured and should have been. They were delivered by the pharmacy at about 4:00 AM and should have been secured when delivered and not left on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2.) R23's diagnoses include hemiplegia & hemiparesis following unspecified cerebrovascular disease affecting left non-dominate side, aphasia, dysarthria, dysphasia, facial weakness and gastrotomy. R23's admission MDS (minimum data set) with an assessment reference date of 11/13/2024, had a BIMS (brief interview mental status) score of 15. A score of 15 indicates that R23 is cognitively intact. R23's functional abilities and goals section, under eating, has a score of 3, which indicated partial to moderate assist is needed with eating. R23's care plan interventions for alteration in nutrition dated 11/18/2024 documented: Provide, serve diet as ordered, texture upgrade on 1/23/2025, from mechanical soft to regular diet. Under the above-mentioned care plan, it had registered dietitian to evaluate and make diet change recommendations as needed. R23's cerebral vascular accident care plan, under the focus area, it had intervention of: Monitor/document ability to chew and swallow. If resident was presenting with problems, obtain an order for speech therapy to evaluate and treat. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 1 (R26) of 3 Residents reviewed. * R26 was prescribed Zoloft (Sertraline), Lexapro (Escitalopram) and Remeron (Mirtazapine) for depression. R26 was also prescribed Prozac (Fluoxetine) for major depressive disorder and generalized anxiety disorder. The facility did not have a written, signed consent for the prescribed psychotropic medications including the risks and benefits to R26's activated Health Care Power of Attorney (HCPOA). Findings Include: The facility's policy Psychotropic Drug Use effective 1/11/21 documents: Objective: . All Residents have the right to be free from unnecessary medications imposed for the purposes of discipline or convenience and not required to treat medical symptoms. Based on a comprehensive assessment of a Resident, the facility will assure that Residents are not given psychotropic medications unless psychotropic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that 4 (R22, R28, R29, R30,) of 4 Residents reviewed for a room change within the facility, were provided with prior written notice, including reason for the room change. *R22 transferred to another room on 1/9/25 and there is no documentation R22 received prior written notice for the reason for the transfer. *R28 was transferred to another room on 12/29/24 and there is no documentation R28 received prior written notice for the reason for the transfer. *R29 was transferred to another room on 1/5/25 and there is no documentation R29's Activated Health Care Power of Attorney (HCPOA) received prior written notice of the reason for the transfer. *R30 was transferred to another room on 12/15/24 and there is no documentation R30's Activated Health Care Power of Attorney (HCPOA) received prior written notice of the reason for the transfer. Findings include: The facility's policy and procedure titled, Change of Room or Roommate Policy, last revised 5/1/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility did not report 1 (R24) of 2 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. On 1/27/25 R24 reported to Surveyor yesterday during the 3rd shift CNA-SSS told R24 to pee & poop in her diaper, refused to place R24 on the bed pan as requested and walked out of R24's room. R24 reported this incident to CNA-TTT. CNA-TTT did not report this allegation and when Surveyor asked NHA-A about this incident, NHA-A was unaware. Findings include: The facility's policy titled Abuse Prevention Program, not dated under the section IV. Internal Reporting Requirements and Identification of Allegations documents, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility did not ensure in response to 1 (R24) of 2 allegations of abuse, and/or neglect the facility prevented further potential abuse. On 1/27/25, R24 reported to Surveyor yesterday during the 3rd shift CNA-SSS told R24 to pee & poop in her diaper, refused to place R24 on the bed pan as requested and walked out of R24's room. R24 reported this incident to CNA-TTT. CNA-TTT did not report this allegation, which allowed CNA-SSS to continue to provide resident care during the rest of the shift until 6:30 a.m. Findings include: The facility's policy titled Abuse Prevention Program and not dated under the section V Protection of Residents documents Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 1 (R27) of 9 Residents reviewed. *On 12/13/24, R27 has a Patient Health Questionnaire (PHQ-9) score of 14, indicating moderate depression. R27 is prescribed Doxepin for depression, anxiety, and sleep and Trazadone for depression. R27 does not have a mood/psychosocial needs care plan in place with person centered interventions. Findings include: The facility's policy and procedure titled, Comprehensive Care Plan, last revised 5/1/24 documents: Policy: . It is the policy of the facility to promote seamless interdisciplinary care for our Residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is used to plan for and manage Resident care as evidenced by documentation from admission through discharge for each Resident. The care plan will identify priority problems and be addressed by the interdisciplinary team, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility's policy and procedure titled, Bathing Policy, dated 3/1/21 documents: Policy: .It is the policy of this facility to provide Residents with a bath or shower in order to cleanse the skin, observe the skin, increase circulation, and prevent infection. Guidelines: 1. All Residents are offered a bath or shower at least once a week or per Resident's preference. 4. Documentation of the Resident's shower or bath must be completed. If the Resident refuses the shower/bath, the nurse needs to be informed for reapproach. If the Resident continues to refuse, the refusal must be documented by the licensed nurse. 2) R27 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Paroxysmal Atrial Fibrillation, Morbid Obesity, End Stage Renal Disease, Adult Failure to Thrive, Dependence on Renal Dialysis, Major Depressive Disorder, and Generalized Anxiety Disorder. R27's admission Minimum Data Set (MDS) completed 12/13/24 documents R27's Brief Interview for Mental Status (BIMS) score to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3.) R30 was admitted on [DATE] with diagnoses of metabolic encephalopathy, thrombocytopenia, hypo-osmolality, hyponatremia, dementia, and end stage renal disease/dialysis. R30's Quarterly Minimum Daily Set (MDS) with the assessment reference date of 12/26/24, documents a Brief Interview for Mental Status (BIMS) score of 99, indicating that R30 is cognitively unable to complete the interview. R30's Cognitive Skills for Daily Decision Making with the assessment reference date of 12/26/24, documents a score of 3, indicating that R30 is severely impaired for daily decision making. R30's Fall assessment dated [DATE] documents a score of 12, indicating that R30 is at high risk for falling. R30's Fall assessment dated [DATE] documents a score of 15, indicating that R30 is at high risk for falling. R30's Fall assessment dated [DATE] documents a score of 7, indicating that R30 is at moderate risk for falling. R30's Fall assessment dated [DATE] documents a score of 15, indicating that R30 is at high risking for falling.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility did not comprehensively assess to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (R22) of 2 Residents reviewed for behavior health services. *R22 has diagnoses of Vascular Dementia Without Behavioral Disturbance, Major Depressive Disorder, Anxiety Disorder, Attention-Deficit Hyperactivity Disorder, Alcohol Dependence and Opioid Abuse. R22 has had significant behavioral changes and has not received behavioral health services in order for R22 to attain the highest practicable physical, mental, and psychosocial well-being. The facility did not offer behavioral health services related to diagnoses of both alcohol and drug substance abuse. Findings include: The facility's policy and procedure Behavioral Health Services Policy implemented 3/21/21 documents: Policy Statement: .It is the policy of the facility to provide Mental Health Services in accordance to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of for 1(R26) of 2 Residents reviewed. * R26 was discharged on 11/26/24 from the facility and was sent home with discontinued medications of Abilify, Prozac, and Zoloft. The facility did not follow procedure of removing the medications from the medication cart and returning the discontinued medication to the pharmacy. * R26 did not receive scheduled medications one hour before or one hour after the scheduled time 22 times between 11/1/24 and 11/26/24. Findings include: The facility's policy Disposal of Medications and Medication-Related Supplies last revised January 2018 documents: Policy .When medications are discontinued by the prescriber or the Resident is discharged and medications are not sent with the Resident, the medications are marked as discontinued and stored in a secure and separate area from the active supply, marked discontinued and securely stored until destroyed. Procedures A. If a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not provide 1 (R27) of 4 Residents reviewed for dietary services, with food accommodations and preferences as listed on the Resident's meal tickets. *R27 did not receive preferred items per meal ticket for breakfast on 1/29/25. Findings Include: The facility's undated policy and procedure Accuracy and Quality of Tray Line Service documents: Policy: Tray line positions and set up procedures will be planned for efficient and orderly delivery. All meals will be checked for accuracy by the fool and nutrition services staff, and by the service staff prior to serving the meal to the individual. Procedure: 4. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu. 5. Staff will refer to the medal identification card/ticket for food dislikes, allergies and other details and substitute approximately for those items. 6. Each meal will be checked for: a. Correct name, room number, and diet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility's policy Infection and Control Guidance for COVID-19 last revised 10/25/24 documents: 2) Adherence to the core principles of COVID-19 infection and prevention to mitigate risk associated with potential exposure as follows: -Facility will provide instructional guidance to all who enter the facility for signs and symptoms of COVID-19 -Proper hand hygiene is performed -Staff will wear a well-fitting facemask that fully covers the mouth and nose, in accordance with CDC guidelines -Instructional signage throughout the facility(hand hygiene, face coverings, social distancing, signs and symptoms of COVID-19, infection control precautions) -Appropriate use of Personal Protective Equipment(PPE) I Implement Source Control Measures 5. Eye protection(goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters II. Universal Use of Protective Equipment for Health Care Providers(HCP) 1. HCP should always use PPE as described below: -NIOSH-approved N95 or higher…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

* On 12/9/24, at 12:19 p.m. Surveyor observed there is a brown water stain on the ceiling tile leading from the 2 South unit into the 2 East [NAME] unit covering approximately one third of the ceiling tile. * On 12/9/24, at 12:29 p.m., Surveyor observed there are multiple scattered pieces of cereal on the piano as well as the piano bench which is located in the 2 South dining room. On 12/9/24, at 2:11 p.m., Surveyor observed there is still multiple scattered pieces of cereal on the piano and piano bench. * On 12/9/24, at 12:32 p.m., on the wall located between R20 & R21's rooms there are four metal pieces on the wall which appeared to have hung a picture from. The bottom two pieces are approximately six inches above the hand rail and are approximately 1/4 inch in size. On 12/10/24, at 4:11 p.m., Surveyor observed the four metal pieces are still on the wall between R20 & R21's rooms. On 12/11/24, at 8:12 a.m. Surveyor Surveyor observed the four metal pieces are still on the wall between R20 & R21's rooms. On 12/11/24, at 8:21 a.m., Surveyor asked Maintenance Director-E how he is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming for 2 (R15 & R11) of 6 residents reviewed for bathing. * R15 & R11 did not consistently receive showers or bed baths. Findings include: The facility's policy titled, Bathing Policy and last revised 11/11/24 under policy documents It is the policy of this facility to provide residents with a bath or shower in order to cleanse the skin, observe the skin, increase circulation, and prevent infection. Under Guidelines documents 1. All residents are offered a bath or shower at least twice a week. 2. If a resident requires a bed bath, a complete bed bath is given two times per week. 3. Residents are encouraged to do as much of their bathing as possible. 4. Documentation of the resident's shower or bath must be completed. If the resident refuses the shower/bath, the nurse needs to be informed for reapproach. If the resident continues…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not provide the necessary respiratory care and services for 1 (R17) of 3 residents receiving oxygen therapy. * R17's oxygen humidification bottle was observed to be empty or dry. Findings include: The facility's policy titled, Oxygen Administration with no date, documents: Oxygen will be safely administered per physician orders. Under the mask section includes documentation of If humidification is used, change humidifier bottle every 7 days or as needed. May label with date and initial. Fill bottle with sterile distilled water as often as needed to keep at proper level marked on bottle. R17's diagnoses include congestive heart failure, chronic respiratory failure with hypoxia, dementia, and anxiety. R17's care plan documents that R17 uses oxygen therapy r/t (related to) CHF (congestive heart failure). Initiated 7/4/24 & revised 8/14/24 documents the following interventions: * Encourage or assist with ambulation as indicated. Initiated 7/4/24. * For residents who should be ambulatory, provide extension tubing or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not ensure proper foot care for 2 (R1 and R3) of 3 Residents. R1 and R3's toenails were very long and in need of trimming. R3 had care planned interventions to monitor feet that was inconsistently implemented. Findings include: 1.) R1 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, obesity and spinal stenosis. The admitting MDS (minimum data set) dated 5/28/24 indicates R1 has moderate cognitive impairment and needs extensive assistance with bed mobility. On 10/9/24 at 2:27 p.m. Surveyor observed wound care on R1's right heel. Surveyor observed R1's toe nails long and in need of trimming. There is no evidence in the medical record R1 was seen by a podiatrist for nail trimming. On 10/10/24 at 9:00 a.m. Surveyor asked Nursing Home Administrator (NHA)-A if the facility has a policy for diabetic foot care. NHA-A stated the facility doesn't have a policy for diabetic foot care. On 10/10/24 at 9:52 a.m. Surveyor interviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility did not ensure 1 (R5) of 7 residents reviewed received medically related social services to attain their highest practicable mental and psychosocial well-being. R5 was admitted to the facility with moderately severe symptoms of Depression. A care plan with resident centered interventions and monitoring was not developed by the facility. R5's Discharge planning evaluation completed on 10/4/24 documented R5's discharge goal and plan as uncertain and unknown. R5 eloped from the facility on 10/18/24. (Cross-reference F689). R5 reported to Surveyor that R5 left the facility because I don't like it here. Upon return to the facility, R5 still verbalizes R5's desire to leave the facility. The facility has not documented any follow up on the 10/4/24 discharge planning evaluation to determine R5's goal and plan for discharge. Findings include: R5 was admitted to the facility on [DATE] with diagnosis (on admission) that include Rhabdomyolysis, Metabolic encephalopathy,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure 1 (R5) of 3 residents were free from significant medication errors. R5 was seen by Psychiatric Nurse Practitioner (NP)-R on 10/8/24. NP-R documented that R5 needed to continue taking Seroquel (an antipsychotic medication) for agitation and start taking Zoloft (an antidepressant medication) for anxiety and depression. The facility did not enter the Zoloft medication order and start offering R5 the medication until 10/14/24. R5 refused multiple doses of Seroquel and Zoloft. The facility did not document that NP-R was made aware of multiple refusals of Seroquel and Zoloft after the 10/8/24 visit. R5 was sent to the emergency room (ER) on 10/19/24 for evaluation. R5 returned to the facility on the same day. The hospital After Visit Summary (AVS) documented that R5 should start doing blood sugar tests and start taking insulin medication. The facility did not acknowledge the AVS instructions and did not address the instructions with the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility did not ensure the coordination of services between hospice and the facility for 2 (R3 & R2) of 2 residents reviewed for hospice care. * R3 did not have hospice services coordinated so that R3 received consistent and professional services for the treatment of R3's pressure injury. * Hospice visit notes were not updated in R2's medical record or in R2's hospice binder until Surveyor requested the information. Hospice was not aware of pressure injuries to R2's bilateral feet. Findings include: The facility's hospice contract 4/14/23 and titled, General Inpatient and Respite Care Skilled Nursing Facility Agreement documents in section 3.3, The facility should designate an IDG (interdisciplinary group) member who is to work with hospice staff to coordinate care provided by the hospice staff. 1.) R3 was admitted to the facility on [DATE], with diagnoses that includes cerebral infarction with dominant side weakness, end stage kidney disease, peripheral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not immediately consult with the resident's physician when there is a need to alter treatment for 1 out of 3 Residents (R) reviewed for physician notification (R5). R5 had a change of condition and the facility failed to consult the physician regarding the change of condition. R5 had weights that increased or decreased out of parameters and the physician was not updated. This is evidenced by: Facility policy, titled, Change in Condition Process, last reviewed 3/01/21, states in part . Policy Statement: The purpose of this policy is to promptly implement a system for a resident having a change in condition. A change in condition is defined as an improvement or decline in their physical, or psychosocial status. Procedure: Change of Condition: 1. When a change of condition or change in baseline is observed and reported, the licensed nurse is responsible for evaluating the Resident's condition. Examples of a condition change are as follows, but not limited to;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure each resident (R) receives adequate supervision and assistance to prevent accidents for 3 of 4 residents reviewed (R4, R3 and R12). R4 has a history of being verbally aggressive towards others. R4 was verbally aggressive towards R12 and verbally aggressive and physically hit R3. R4 was not supervised when he was out of his room and interacting with other residents. Evidenced by: R4 was admitted to the facility on [DATE]. R4's diagnoses include metabolic encephalopathy, dementia and diabetes. R4's most recent MDS (Minimum Data Base), with an ARD (Assessment Reference Date) of 6/19/24, indicates R4 has moderate cognitive impairment and can independently wheel his wheelchair. R4's care plan focus areas include, in part, the following: *The resident is/has potential to be verbally aggressive r/t (related to) dementia w/ (with) delusions and hallucinations, ineffective coping skills, mental/emotional illness, poor impulse control. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure a safe, clean, comfortable, and homelike environment for 102 residents residing in the facility. * In R67's bathroom, on the wall to the right of the toilet, there is a brown material which appeared to be BM (bowel movement) in two different areas. On the floor to the right of the toilet, there is a piece of BM and multiple areas of what appeared to be BM splattered on the floor. There are orange stains on the floor of the bathroom near the sink. Under R67's bed towards the head of the bed, there are multiple pieces of paper and dirt. Under R67's bed there are multiple pieces of paper, food, and dirt particles. This was observed on multiple days & times. * On the floor between R53's bed and the wall, along the cove base there is a piece of candy, a straw, and multiple pieces of paper and food particles. Under the head of the bed there is a fork, plastic bag, and multiple pieces of food. The window blind is broken and there is a pair of glasses on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for non-pressure wounds for 4 (R26, R77, R53, and R99) of 7 residents reviewed. *R26 had a surgical wound to the back. The treatment order for a wound vac was not transcribed into the Treatment Administration Record (TAR) as written, treatments orders had conflicting administration times that were not clarified, and treatments were not consistently signed out as being administered. *R77 had multiple Moisture Associated Skin Damage (MASD) wounds to abdominal skin folds, under breasts, behind knees, skin folds across chest, and midline folds that would appear and resolve over time. Multiple treatments were ordered to the same area. A new non-pressure wound was identified on 6/28/2024 on the left triceps and a treatment was ordered; the order was not entered onto the TAR for nursing to sign out when administered. *R53 was observed with an undated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R99) of 1 residents who voiced a desire to self administer their medication was assessed to determine if able to self administer medication. Findings include: The facility's policy titled, Medication Administration-General Guidelines dated 2006 American Society of Consultant Pharmacists and Med-Pass, Inc. (Revised December 2019) under procedures for Administration #14 documents Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications (See IIA10: SELF ADMINISTRATION OF MEDICATIONS). R99's diagnoses includes osteomyelitis of vertebra, sacral & sacrococcygeal region, anxiety disorder, and depression. The admission MDS (minimum data set) with an assessment reference date of 5/1/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. On 7/11/24, at 11:17 a.m., R99 informed Surveyor she had asked to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility did not ensure 1 (R67) of 5 residents was provided with personal privacy. On 7/9/24 during a toileting observation, R67's bathroom door was not closed and R67's roommates (R502) privacy curtain was not closed. R502 was observed on his right side, not asleep, and was able to see R67 sitting on the toilet. Findings include: The facility's policy titled, Privacy and Confidentiality last revised 5/9/22 for Policy documents The resident is treated with consideration and respect and full recognition of his/her dignity and individuality, including privacy in treatment and in care for personal needs. R67's diagnoses includes hypertension, dementia, depressive disorder, and anxiety disorder. The annual MDS (minimum data set) with an assessment reference date of 4/16/24 has a BIMS (brief interview mental status) score of 5 which indicates severe cognitive impairment. R67 is assessed as requiring supervision or touching assistance for toileting hygiene & toileting transfer and partial/moderate assistance for chair/bed to chair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 2 (R501 and R99) of 7 residents reviewed received a prompt resolution of grievances filed, including steps taken to investigate the grievance, a summary of pertinent findings, conclusion, statements as to whether the grievance was confirmed or not confirmed, corrective actions taken by the facility, and the date the written decision was issued. R501 filed three grievances with the facility and there is no evidence if the grievances were confirmed or not or if R501 was informed of the corrective actions taken by the facility and resolution. R99 filed grievances with the facility and there is no evidence if the grievances were confirmed or not or if R99 was informed of the corrective actions taken by the facility and resolution. Findings include: The facility policy and procedure entitled Grievance Policy dated 12/12/2022 documents: PROCEDURE: 1. When a grievance is noted (either verbal or written), the resident or their representative may speak to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not develop and implement and effective discharge planning process focusing on the resident's discharge goal, preparation for transition and reduction in factors leading to preventable readmission for 1 (R501) of 1 residents reviewed for discharge planning. R501 was living independently in the community when she suffered a fall, was transferred to the hospital where she was diagnosed with a subdural hematoma, left elbow fracture, right ring finger fracture and an elevated A1C (blood test that provides information about the average levels of blood glucose, blood sugar over the last 3 months). R501 underwent surgical repair of the left elbow fracture and was newly diagnosed with Diabetes and started on insulin. R501's hospital discharge instructions, dated [DATE], document diabetes discharge instructions including using a glucose meter to check blood sugars 1-2 times per day before meals or at bedtime varying the meals/times you are checking; record all finger…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility did not ensure 1 (R99) of 1 residents received the necessary services to maintain ability to practice good grooming and personal hygiene. R99 did not consistently receive showers twice a week. Findings include: The facility's policy titled, Bathing Policy dated 3/1/21 with a revised date of 4/29/24 under Policy documents, It is the policy of this facility to provide residents with a bath or shower in order to cleanse the skin, observe the skin, increase circulation and prevent infection. Under Guidelines documents: 1. All residents are offered a bath or shower at least twice a week. 2. If a resident requires a bed bath, a complete bed bath is given two times per week. 3. Residents are encouraged to do as much of their bathing as possible. 4. Documentation of the resident's shower or bath must be completed. If the resident refuses the shower/bath, the nurse needs to be informed for reapproach. If the resident continues to refuse, the refusal must be documented by the licensed nurse. R99's diagnoses includes osteomyelitis of vertebra,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

UNCORRECTED AT VERIFICATION VISIT Based on observation, interview and record review, the Facility did not ensure that Residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R67 & R53) of 5 Residents reviewed for pressure injuries. * R67 did not have a pressure relieving cushion in the wheelchair according to R67's plan of care. * Wound Physician-H's 6/25/24 order was incorrectly transcribed by the facility. R53's treatment with a start date of 5/29/24 for zinc oxide was not discontinued after Wound Physician-H on 7/2/24 ordered a treatment of Santyl, alginate calcium, and gauze island with border dressing daily. Wound Physician-H's discontinued the treatment of Santyl, alginate calcium and gauze island with border dressing and ordered Leptospermum honey, alginate calcium and gauze island with border dressing once daily on 7/9/24. This treatment was not implemented until 7/11/24. R53 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY UNCORRECTED AT VERIFICATION VISIT Based on interview and record review the Facility did not ensure each Resident received adequate supervision to prevent accidents for 2 (R67 & R53) of 5 Residents. * R67, who is at high risk for falls, was not transferred with a gait belt. * R53's bed was observed not at the lowest position and the call light was not in reach according to R53's care plan. Findings include: 1.) R67's diagnoses includes hypertension, dementia, depressive disorder, and anxiety disorder. The last fall risk assessment which is dated 3/26/24 has a score of 12 which indicates high risk for falls. The annual MDS (minimum data set) with an assessment reference date of 4/16/24 has a BIMS (brief interview mental status) score of 5 which indicates severe cognitive impairment. R67 is assessed as requiring supervision or touching assistance for toileting hygiene & toileting transfer and partial/moderate assistance for chair/bed to chair transfer. R67 is occasionally incontinent of urine and always incontinent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

UNCORRECTED AT VERIFICATION VISIT Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 3 (R67, R53, & R99) of 5 Residents. * Staff did not perform appropriate hand hygiene during toileting observations for R67. * Appropriate hand hygiene was not observed during a treatment for R53 and staff were not wearing gowns during care observation for R53 who is on EBP (enhanced barrier precautions). * LPN (Licensed Practical Nurse)-F did not wear a gown during a pressure injury treatment observation with R99 who is on EBP. Findings include: The facility's policy titled, Enhanced Barrier Precaution dated 3/25/24 under policy documents It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Under Policy Explanation and Compliance Guidelines includes documentation of 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions (in accordance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure sufficient nursing staff was available to provide nursing and related services to assure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being as determined by the resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment potentially affecting 104 of 104 residents in the facility. PBJ (Payroll Based Journal) staffing data report from CMS (Centers for Medicare and Medicaid Services) triggered for low weekend staffing October through December of 2023. R32 voiced staffing concerns during the Resident Council interview. Findings include: Surveyor reviewed the Facility assessment dated : 09/2018 and last reviewed: 4/29/24. Dates Reviewed at QAA (Quality Assessment and Assurance)/QAPI (Quality Assurance and Performance Improvement): 4/30/24. The following is documented for the Staffing Plan: The below graph displays the total typical number of staff that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review, the facility did not ensure food was stored, prepared and served in a sanitary manner. This practice had the potential to affect 104 of 104 residents residing in the facility. * Dietary Aides DD and EE were observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. * Dietary Aides DD and EE were observed not changing gloves and washing hands after touching non-sanitized food surfaces. * Food temperatures were observed not obtained at breakfast service on 1st and 2nd floor kitchenettes. * Staff did not ensure that food was labeled with open or use-by dates. * Staff did not wear beard restraints while working in the kitchen. * Unit refrigerator temperatures were not being monitored consistently and medication was observed in one refrigerator with food. Findings include: The facility policy and Procedure titled, Hand Washing with no date, states in part: Procedure: Hands and exposed portions of arms (or surrogate prosthetic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure the infection control program was implemented which had the potential to affect all 104 residents. * From December 2023 to May 2024 the facility did not monitor infections, surveillance, tracking and trending of infections were not completed, and infection rates were not completed. * The facility does not have a current comprehensive water management plan that includes flow charts specific to the facility to determine areas of concern or interventions implemented on closed units to prevent the spread of opportunistic pathogens (Legionella) in the facility's water systems, and the water management plan was not included in the facility assessment. * R17, R81 and R75 were observed with indwelling medical devices, without indication they were on enhanced barrier precautions to prevent potential infections. Findings include: 1.) The facility's Infection Control - Surveillance of Infections Policy and Procedure dated 2/4/21 documents:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure they implemented an effective antibiotic stewardship program with the potential to affect all 104 residents in the facility. Review of the facility infection surveillance logs for residents on antibiotics, indicate antibiotic use without documentation of appropriate use, surveillance, and tracking information. Findings include: The facility's policy and procedures for Antibiotic Stewardship dated 2/4/21 was reviewed and indicates the following: POLICY STATEMENT: It is the facility's policy to focus on improving antibiotic use through the Antibiotics Stewardship Program while optimizing the treatment of infections and reducing the risk for possible adverse events associated with antibiotics abuse. PROVISION AND PROCEDURE: 1. The Infection Prevention and Control Coordinator (IPC Coordinator), along with the Medical Director, is responsible for the following: a. Ensuring policies and procedures governing the control of infections and communicable diseases are implemented. b. Ensuring systems for identifying, reporting,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility did not ensure a clean, sanitary and homelike environment. This was observed on 4 of 6 Units in the facility. -2 [NAME] Unit resident rooms observed with dirty, sticky floors with debris scattered about, resident beds without fitted sheets and dining room observed with dirty, sticky and stained floors. -2 South Unit clean linen room observed with incontinent products, used gloves, linen, gripper socks and debris scatter on the floor. -2 East Unit (currently closed but remains accessible to residents and staff. The unit is adjacent to the 2 [NAME] Unit dining room and common area.) 2 East Unit observed with debris on the floor, medical supplies in unoccupied rooms, garbage cans full of debris, food and used linens. -During Resident Council group meeting R32 expressed concerns related to housekeeping and lack of linens. -Surveyor observed second floor kitchenette area to be uncleanly. -Surveyor observed a pill on the floor in first floor main hallway. Findings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility did not implement their abuse prevention policy by ensuring 3 of 8 facility staff had the necessary background information disclosure (BID), form completed upon hire in order to work at the facility. The BID form is 1 of a 3 part screening process which requires applicants/employees to disclose various information such as; if they have any criminal charges pending against them, if they have ever been convicted of a crime in federal, state, local, military, and tribal courts, if any government agency found the individual to have committed child abuse or neglect or if they have ever been found to have abused or neglected any person or client. The deficient practice had the potential to affect all 104 residents residing in the facility at the time of the survey. Certified Nursing Assistant (CNA)-R was hired on 12/1/20 and there is no evidence the BID was obtained. CNA-S was hired on 1/16/19 and the facility obtained a BID form on 5/21/24. CNA-T was hired on 12/1/20 and the facility obtained a BID form on 5/20/24. Findings include: The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that all medications were labeled in accordance with standard of practice for 3 of 6 medication carts (1 West, 1 South, and 2 West) and 2 of 3 (1 [NAME] and 1 South) medication storage rooms with the potential to affect 51 of 104 residents residing in those units. Findings include: ~ On [DATE] at 10:17 am, the medication cart on 1 [NAME] wing was observed and the following was found: * A bottle of partially used mucus relief tablets was not dated when opened. * A bulk bottle of partially opened Vitamin D 1250 mcg tablets was not dated when opened. * A bulk bottle of Calcium 600 mg tablets was not dated when opened. * A bulk bottle of Clear Lax Polyethylene Glycol was not dated when opened. * A bulk bottle of Aspirin 81 mg tablets was not dated when opened. * A bottle of glucose test strips partially used was not dated when opened. On [DATE] at 10:21 am, Surveyor interviewed Licensed Practical Nurse (LPN)-Z and showed her the bottle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not implement an established process of assessing a resident's cognitive ability to understand an arbitration agreement before obtaining a signature for 3 (R27, R64, R34) residents; and did not ensure the staff responsible for the arbitration agreement was able to thoroughly explain the agreement for complete understanding. This deficient practice had the potential to affect 47 of 104 residents who resided in the facility that entered into the binding arbitration agreement. Findings include: Per the regulation at 42 CFR (Code of Federal Regulations) under 483.70 (n) Binding Arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) Agreements, Binding Arbitration Agreement (Arbitration Agreement) was defined as, .a binding agreement by the parties to submit to arbitration all or certain disputes [disagreements, controversies, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 1 (R82) of 4 sampled residents with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and provide dignity for residents. *R82 was observed multiple times with their catheter drainage bag system uncovered. Findings include: 1. R82 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder and urinary retention. R82's Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicates R82 requires maximal assist with 1 person for incontinence cares. R82 requires use of a urinary catheter for bladder elimination. On 5/19/24, at 10:18 AM, Surveyor noted R82's Foley catheter bag to be hanging on the back of their wheelchair. Surveyor did not observe a privacy bag in place at this time. On 5/19/24, at 12:45 PM, Surveyor noted R82's Foley catheter bag to be hanging on the back of their wheelchair. Surveyor did not observe a privacy bag in place at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure the resident who has not been adjudged incompetent designated a representative and delegated that representative to speak for the resident for 1 (R16) of 1 residents reviewed. R16 did not have an activated Power of Attorney (POA). R16 did not sign any facility documents for consent to treat, medication consents, the admission agreement, and the Do Not Resuscitate State form. All documents were signed by an individual that was not designated to speak on R16's behalf until R16 was deemed incompetent and the POA was activated. Findings include: R16 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, dysphagia, congestive heart failure, depression, and deaf. R16's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R16 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 10. Subsequent MDS assessments assessed R16 as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure grievances were documented or make prompt efforts to resolve grievances for 1 (R58) of 4 residents reviewed for grievances. *R58 had two cell phones go missing and no grievance forms were completed or followed up on and R58 had a concern of a pair of missing pants that were not resolved. Findings: The facility policy and procedure entitled Grievance Policy dated 12/12/2022 documents: PROCEDURE: 1. When a grievance is noted (either verbal or written), the resident or their representative may speak to any member of the facility staff and report the nature of the grievance or submit a written grievance form. 2. At the time of the grievance, the staff member will attempt to resolve the issue or direct the resident/representative to the appropriate department head or staff member for further action and/or notify the grievance officer. 3. Upon notification of a resident grievance, information sufficient to identify the individual registering the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure the Residents's medial record included documentation as to the reason for discharge and appropriate information is communicated to the receiving health care institution or provider for 2 (R64, R96) of 2 Residents reviewed for transfer/discharge. R64 was transferred to the hospital on 3/9/24. The Facility did not document the reason R64 was transferred, where R64 was transferred, the effective date of the transfer, their transfer appear rights and who to notify if choosing to appeal the transfer. R96 was transferred from the facility and admitted to the hospital on [DATE] and 3/4/24. No documentation was found of R96's medical status prior to leaving the facility. Evidenced by: Policy review: Notice of Requirements before transfer/ discharge, dated 5/1/2021 Intent: It is the policy of the facility to notify the resident and or their legal guardian of the transfer and/discharge according to state and federal regulations. Procedure: (includes)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that 3 of 3 (R158, R259, R261) residents reviewed for discharge received a completed discharge summary in order to communicate necessary information to the resident, continuing care provider, and other authorized persons at the time of the anticipated discharge. R158 was discharged from the facility on 4/4/24 and there is no documented evidence a discharge summary was completed to include a recapitulation of stay, final summary of resident status at discharge, reconciliation of medications and post discharge plan of care. R259 was discharged from the facility on 4/26/24 and there is no documented evidence a discharge summary was completed to include a recapitulation of stay, final summary of resident status at discharge, reconciliation of medications and post discharge plan of care. R261 was discharged from the facility on 5/1/24 and there is no documented evidence a discharge summary was completed to include a recapitulation of stay, final summary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, 1 (R82) of 5 dependent residents reviewed were not provided with bathing assistance in accordance with their care plan. Findings include: R82 was admitted to the facility on [DATE] with diagnoses including quadriplegia, neuromuscular dysfunction of bladder and urinary retention. R82's admission MDS (Minimum Data Set) assessment dated [DATE] indicates R82 requires maximal assist with 1 person for showering and bathing. Surveyor noted that R82's Quarterly MDS assessment dated [DATE] does not indicated R82 demonstrated any rejection of care with ADL (Activities of Daily Living) assistance throughout the observation period. On 5/19/24, at 10:18 AM, Surveyor made observations of R82. R82 was noted self-propelling their wheelchair down the unit hallway towards their room. R82 was non-interviewable at the time of this observation. Surveyor noted R82's appearance with long, unkempt facial hair and uncombed hair that appeared unwashed. Surveyor reviewed R82's CNA (Certified Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility did not ensure a resident with a g (gastrostomy)-tube received the appropriate treatment. This was observed with 1(R17) of 1 resident reviewed for tube feeding. -R17 was observed receiving a un-prescribed tube feeding formula; tube feeding formula bag and water bag did not include the date, time the tube feeding began, the rate at which the feeding was being administered or the total run time. Findings include: The facility's policy and procedure Enteral Tube Feeding, dated 6/11/2022, which documents to provide enteral feeding as ordered by the physician. The procedure includes: 1.) verify the physician orders; . 4.) compare the label on the eternal feeding with the physician order. On 5/19/24, at 10:12 AM, Surveyor observed R17 in bed. R17 had a tube feeding bag of Osmolite 1.5, and a water bag, hanging on a pole with a rate pump attached. The tube feeding was a 3/4 empty. Surveyor observed there was no date, rate of feeding or total run time documented on the tube feeding formula bag or water bag. Surveyor noted there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not act upon the recommendation of the pharmacist per the drug regimen review for 2 (R64, R11) of 5 residents reviewed for unnecessary medications. On 2/29/24, the pharmacist reviewed R64's drug regimen and made a recommendation. The facility was not able to provide a copy of the pharmacist's recommendation or were they had to provide evidence the physician was aware of the recommendation and acted upon it. R11's record indicated pharmacy recommendations were noted on 3/31/24. R11's record does not include the pharmacy reviews or specifically note what was reviewed or noted. Findings include: 1.) R64 was admitted to the facility on [DATE] with diagnosis that included congestive heart failure, Parkinson's disease, Pneumonia, muscle weakness and type 2 diabetes. A review of the most recent quarterly MDS (Minimum Data Set), dated 5/3/24 indicates R64 receives Antipsychotic and Antidepressant medications. The MDS also states that yes- antipsychotic's were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure adequate monitoring of side effects for antipsychotic medications was completed timely for 2 (R85 and R64) of 5 residents reviewed for unnecessary medications. *R85 received the antipsychotic medication aripiprazole and R85 had no record of having an Abnormal Involuntary Movement Scale (AIMS) assessment completed. *R64 received the antipsychotic medication brexpiprazole and the last AIMS assessment was completed on 4/5/2023, one year ago. Findings include: The facility policy and procedure entitled AIMS Side Effect Monitoring dated 5/3/2022 states: Purpose: Abnormal Involuntary Movement Scale (AIMS) - records the occurrence of tardive dyskinesia (TD - a neurological disorder characterized by involuntary movements of the face and jaw) of residents receiving psychotropic medications. To assess the presence of movement and non-movement side effects, and to follow the severity of TD over time. Responsibility: RN/LPN Guidelines: The examination will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R258) of 2 residents reviewed had complete and accurate documentation in their medical record. R258 was on hospice services while at the facility and died on [DATE]. The facility did not document the assessment that was completed when R258 died. The facility did not document when hospice was made aware of R258 death. The facility also documented assessments from a fall dated [DATE] after R258 death. Findings include: Surveyor reviewed R258 medical record and located a Notice of Removal of a Human Corpse from a facility form dated [DATE] that is signed by hospice provider pronouncing R258 death at 5:55 p.m. There are no nurses notes indicating R258 died. There isn't any documentation of an assessment when R258 died. There is no documentation hospice provider was notified of the death. There are also 3 nurses notes dated [DATE] indicating a fall R258 sustained. On [DATE] at 3:00 p.m. Surveyor explained to Director of QA (quality assurance)-D,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure information including the hospice plan of care, the hospice election form, and communication of hospice visits was available to facility staff from the hospice agency for 1 (R16) of 1 resident reviewed for hospice services. R16 did not have any hospice records of visits after 2/22/2024 in the medical record. No documentation was found of the hospice agency attending any care conferences to coordinate care between the facility and the hospice agency. Findings: 1.) R16 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, dysphagia, congestive heart failure, depression, and deaf. R16's Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated R16 was severely cognitively impaired and unable to answer the Brief Interview for Mental Status (BIMS) questions. R16's POA was not activated. The Significant Change MDS assessment was completed due to R16's election of hospice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure a resident fall was comprehensively assessed, and documented in the medical record. This was observed with 1 (R1) of 3 residents reviewed with falls in the facility. R1 had a fall on 2/7/24 that was not document as being comprehensively assessed for injury. An assessment for possible care plan revisions also was not completed. Findings include: The facility's policy and procedure Fall Policy, dated 5/17/21, was reviewed by Surveyor. The Procedure includes the following: a. Check resident for injuries. b. Vital signs. c. Neuro-checks for head injuries or un-witnessed falls. e. Notify physician, family/responsible party of fall. h. Document in the Nurses Notes. j. Each nurse will observe the resident and document for 72 hours in the resident's medical record. 2. Quality Assurance Guidelines e. The care plan is to be updated with any new interventions. h. The Interdisciplinary Plan of Care team will meet within the same period and discuss the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure 2 of 3 residents (R7 and R8) of eight sampled residents observed with empty medications cups at bedside were assessed for self-administration of medication. This failure had the potential for medications not being taken when required. Findings include: Review of facility's policy titled, Administration Procedures for all Medications, with a revision date of January 2018, showed: obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medications administration. After administration, return to cart, replace medication container (if multi-dose and dose remains), and document administration in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) and controlled substance sign out record, if indicated. During an observation of the facility on 02/08/24 at 10:30 AM, empty medicine cups were noted to be at bedsides. During another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review, the facility failed to ensure the wound care was documented as being provided for 2 of 2 residents (R1 and R5) reviewed for non-pressure wounds. This failure to provide wound care had the potential to affect the healing process of the wounds. Findings include: Review of the facility policy titled Wound Management, revised 05/01/22, showed: Purpose: The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as non-pressure related wounds. Process .Adherence to this program is under the direction of the DON. 1. Review, verify and follow physician's order for procedure . 1. R1 was admitted on [DATE] and was readmitted on [DATE], with medical diagnoses that included dialysis dependent chronic kidney disease, type II diabetes, and moderate protein calorie malnutrition. R1's November 2023 Treatment Administration Record (TAR) included, Wound Care for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to ensure 1 of 3 residents (R3) reviewed for limited mobility, received restorative services as needed to address limited mobility, to maintain or improve mobility for the goal to reach the maximum practicable independence. Findings include: Review of the facility's policy titled Restorative Services, dated 02/01/21, showed: .The facility will provide restorative services such as but not limited to walking, transfer training, bowel and or bladder training, bed mobility, Range of Motion (ROM), splint and brace, eating and/or swallowing, amputation/prostheses care and communication, when necessary, as indicated by the assessment of the interdisciplinary team. Review of the facility's policy titled Therapy Screening Policy, dated 02/01/21, showed: Screening & Restorative Policies .Restorative Program/Therapy to Nursing Communication form should be completed and dated. Form should be completed at evaluation, discharge, and with any status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, the facility did not ensure there was a Registered Nurse (RN) on duty for a minimum of eight consecutive hours a day, seven days a week. This had the potential to affect all 110 residents of the facility. -In the previous four months the facility did not have eight consecutive hours of RN coverage on 14 days. Findings: On 10/05/23, Surveyor reviewed nursing staff schedules from June-October 2023. Surveyor identified there was not adequate RN coverage on the following dates: -06/10/23 -06/24/23 -06/25/23 -07/08/23 -07/15/23 -07/22/23 -07/23/23 -08/05/23 -08/19/23 -08/20/23 -09/02/23 -09/03/23 -09/16/23 -09/17/23 -10/01/23 On 10/05/23 at 2:00 PM, Surveyor interviewed Director of Nursing (DON) B. DON B reported there was RN coverage as she remembered working over the weekend. Surveyor requested evidence of RN coverage for 14 dates. Surveyor did not receive evidence requested.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment; this has the potential to affect 9 residents (R) R22, 35, 38, 43, 44, 16, 19, 23, 17) throughout the building and residents residing on the first floor. The facility did not repair corner guards, leaving areas that were hard to clean and potentially hazardous. Residents (R) R22, R36, R38, R43, and R44's rooms were found to have briefs, trash, and crumbs on their floors, and rooms had large yellow/orange stains around the toilets. The first-floor hallway and resident common areas have damage to walls, toilets, doors, and floors. R16 did not have appropriate linens for the bed, resident's room had a large pile of laundry on the floor, multiple items on the floor including oxygen mask, C-Pap mask and tubing, dirty towel, plastic cup, paper towels, and tissues. Floor appeared dirty needing to be swept and mopped. There were stains on the walls and floor around…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that a resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 of 5 residents (R33, R34, R31, and R26) reviewed. The facility did not ensure R33 and R34 were administered insulin appropriately based on the observation of Licensed Practical Nurse (LPN) not priming the insulin pen before administration. The facility did not ensure all insulins have an opened date recorded when insulins were opened for R31, R26, and R34. The facility did not ensure proper storage of insulin pens for R33, R31, R26, and R34. The insulin pens were all stacked together in the top drawer of the South medication cart. Insulin pens were not in divided areas labeled with residents' names. This is evidenced by: The facility policy, entitled Insulin Pen Administration Policy and Procedure, not dated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility did not ensure staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. An abbreviated medication administration observation was conducted in which Licensed Practical Nurse (LPN) II did not wash or sanitize her hands between residents (R), affecting R24, R30, R29, R28, R27 and R25, did not don gloves prior to obtaining a blood glucose level on R34 and did not sanitize the multi-resident glucometer machine between residents R29 and R32. Staff did not perform hand hygiene when changing gloves during dressing change for R15. Care observations were completed on R8 in which staff did not perform hand hygiene after completion of a dirty task and prior to conducting a clean task, potentially contaminating additional presumed clean items and the resident. The facility did not transport soiled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not notify the resident's family with a significant change in the resident's condition. This occurred for 2 residents (R17 and R13) of 4 residents reviewed. R17's responsible party, power of attorney (POA) was not notified when weights were not obtained as ordered and a significant weight loss occurred during the time the weights were not obtained as well as notification of pressure injury (PI) progression and support surface use for PI prevention. The facility did not notify R13's power of attorney (POA) after R13 was found to have a fractured leg. This is evidenced by: R17 was admitted to the facility on [DATE] with diagnoses in part included traumatic subdural hemorrhage, cerebral infarction, hemiplegia, and hemiparesis to left non-dominant side, muscle weakness, cognitive communication deficit, and mild neurocognitive disorder. R17's admission MDS (minimum data set) assessment dated [DATE]: Brief Interview of Mental Status (BIMS) was 14, cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not maintain personal privacy during personal cares for 2 of 36 residents (R), R3 and R18. Staff did not close privacy curtain when completing cares for R3 while roommate R7 remained in the room and observed the care being provided. Staff did not close privacy curtain when completing cares for R18. Findings: Based on a reasonable person concept, a person who is unable to provide for their own personal privacy of their body, would want their privacy to be provided by staff. This would include ensuring that a person's body be covered in a way to protect them from view of others; including the private, normally covered areas of their body. Surveyor reviewed facility policy titled, Resident Rooms, dated 02/01/21. Policy reads in part . c. Be designed or equipped to assure full visual privacy for each resident. R7 was admitted to the facility on [DATE]. R7's Minimum Data Set (MDS) assessment completed on 08/30/23 confirmed R7 scored 15/15 during Brief Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not ensure 1 of 11 residents (R2) reviewed for dependence of staff for Activities of Daily Living (ADLs), received the necessary services to maintain good grooming and personal hygiene. Facility also did not ensure practices were in place to identify, intervene and educate R2 when cares were refused. R2 was to receive daily sponge bathing with showers twice weekly on Wednesday mornings and Saturday evenings (per bathing/shower task documentation). There was no evidence located that facility provided these services to R2. This is evidenced by: The facility policy titled Activities of Daily Living, dated 1/1/2021, states, in part, It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each residents quality of life by ensuring all staff . understand the principles of quality of life and honor and support these principles for each resident; and that the care and services provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that pain management was provided consistent with standards of practice for 1 of 6 sampled resident (R7). The facility did not thoroughly assess R7's pain according to standards of practice. This is evidenced by: The facility policy titled, Pain Management Program dated 01/11/21, reads in part . Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: g. Facial expressions: grimacing, frowning, fear, grinding of teeth. k. Sighing, groaning, crying, breathing heavily. Assessment and evaluation by appropriate members of the interdisciplinary team may include: a. Asking the patient to rate the intensity of pain. e. Determining factors that make pain better or worse. i. Note all treatments the patient is receiving for pain, including non-pharmacological therapies. R7 was admitted to the facility on [DATE]. Diagnoses include dependence on dialysis, left leg above the knee amputation, right leg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure consistent communication for 1 of 3 residents (R1) reviewed who receive dialysis services. R1 was readmitted from the hospital on [DATE] with a new order for intravenous (IV) antibiotics. The medication order was not relayed to the pharmacy by the facility or dialysis center. Findings include: The facility policy, entitled Dialysis Policy, dated 02/01/21, states: The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility policy, entitled Admission/readmission Policy, dated 10/21/21, states: Information about resident admission is communicated in a timely manner to the appropriate departments. The admitting nurse completes the nursing assessment and obtains admitting orders. Once the admitting orders are verified, the orders are transcribed onto the POS, MAR, and TAR. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility must ensure that a resident is free of any significant medication errors for 1 of 3 residents (R1) reviewed that received dialysis services. The facility did not ensure R1 was administered intravenous (IV) antibiotic on three separate occasions as ordered from physician. The order was not transcribed, entered in R1's medication record, and staff did not provide evidence that the medication was available to administer. This is evidenced by: The facility policy, entitled Admission/readmission Policy, dated 10/21/21, states: Information about resident admission is communicated in a timely manner to the appropriate departments. The admitting nurse completes the nursing assessment and obtains admitting orders. Once the admitting orders are verified, the orders are transcribed onto the POS, MAR, and TAR. The medication orders are then transferred to the pharmacy. The facility policy, entitled Medication Administration, dated 12/2019, states: Current medications,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility did provide a clean homelike environment on 2 of the 4 (2 east and 1 south) units observed which had the potential to affect 17 of 17 residents residing on the 2 east unit and 20 of 20 residents residing on the 1 south unit. *Surveyor observed two garbage/soiled linen bins in the hallway of 2 east. These bins were visibly full of malodorous contents. *Surveyor observed a pile of bed linens lying on the floor in the hallway of 1 south. Findings include: On 05/10/23 at 1:32 PM, Surveyor entered the 2 east unit and noted 2 bins in the hallway. One was on each side of the hallway so that Surveyor had to walk between the two bins to continue down the hall. Each bin had a clear garbage bag and the contents inside the bags were visible. One bin clearly contained soiled garbage, briefs etc. and the other bin was full of white items only, Surveyor could not tell if it was garbage or soiled linens. Surveyor noted a strong odor of feces and urine as Surveyor approached the bins, the odor was strongest as Surveyor passed by the bins and the odor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not make a prompt effort to resolve grievances for 4 (R41, R52, R10, R67) of 7 residents who had expressed grievances/concerns to the facility. *R41 had voiced concerns to the facility regarding interaction with two agency certified nursing assistants (CNAs) during cares. The facility did not investigate and provide resolution to a grievance voiced by R41. *Resident Council members expressed concerns to administration staff during Resident Council meetings in November and [DATE] and January, February and [DATE] regarding concerns with Hoyer lifts and batteries not being charged properly. The grievance documents do not identify how the grievances were investigated, if interviews with staff/residents were completed, or the outcome of the investigation. Resident Council Minutes did not include action taken regarding the concerns voiced by residents. Findings Include: The facility policy, entitled Grievance Policy, dated [DATE], states: .Residents have the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not provide a bed hold notice upon transfer to the hospital as required for 1 (R21) of 4 residents reviewed for hospitalization. *R21 was hospitalized on [DATE] and 3/25/23. The facility did not provide a bed hold notice for R21's hospitalizations on 3/10/23 and 3/25/23. Findings include: 1. R21 was admitted to the hospital on [DATE] and 3/25/23. Surveyor reviewed R21's medical record. Surveyor noted their is no documentation a bed hold notice was provided to R21 or their responsible party for their hospital transfer and admission on [DATE] and 3/25/23. On 5/10/23, at 3:05 PM, Surveyor conducted an interview with Nursing Home Administrator (NHA)-A. NHA-A notified Surveyor that there was no documentation in R21's record indicating R21 and R21's responsible party were provided with a bed hold notice. No further information was provided by the facility at this time.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 (R61, R27) residents reviewed for activities of daily living. R61 required assistance with bathing/showering and grooming. Assistance was not provided with grooming until Surveyor inquired and assistance with a shower wasn't provided during the onsite survey. R27 required assistance with nail care. R27 requires assist of 1 staff for Activities of Daily Living. Findings include: R61 was admitted to the facility on [DATE] with diagnoses of chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease, stage 3 unspecified, primary hyperparathyroidism, major depressive disorder, recurrent, moderate, secondary parkinsonism, unspecified, morbid (severe) obesity due to excess calories. R61's Quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not maintain acceptable parameters of nutritional status, such as usual body weight for 2 of 4 (R1 and R24) residents reviewed for weight loss. *R1's dietician recommended a re-weight due to a 7.49% weight loss in under two months. The facility did not document a reweight for three months. *R24 did not have weights completed as ordered. Findings include: The facility Policy and Procedure titled: Weight Management dated 3/1/21 documented (in part) . .Policy Statement: The facility's policy is to provide care and services to weight management by State and Federal regulations. Procedure: 1. All residents admitted to the facility will be weighed according to the following schedule: Upon admission and weekly times four weeks. 2. All residents will be weighed every month unless otherwise ordered by the physician or deemed necessary by the dietician or the interdisciplinary team. 3. Dietary should evaluate weights, notify appropriate disciplines of significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not ensure a resident received the appropriate treatment during enteral feeding through a gastrostomy tube to prevent possible complications for 1 (R14) of 1 resident reviewed for enteral feeding. R14 received enteral feeding without ensuring the gastrostomy tube was appropriately placed in the stomach prior to the medication administration. On 5/9/23, Licensed Practical Nurse (LPN)-O did not auscultate or aspirate the gastronomy tube prior to administering the medication. Findings: The facility policy and procedure entitled, Enteral Tube Feeding dated 6/11/22 states: The facility policy is to provide enteral feedings as prescribed by the physician . 9. Check placement/gastric residual volume per physician's orders. R14 has dysphagia and receives nothing by mouth, requiring use of a gastrostomy tube (g-tube) for all nutrition and medication administration. On 5/9/23, at 10:05 AM, R14 was observed during the medication pass task. R14 was scheduled to receive enteral feeding at the time of the medication pass.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.